Provider Demographics
NPI:1972964849
Name:BURKETTE IKEBATA, NICOLE S (MD, MPH)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:S
Last Name:BURKETTE IKEBATA
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:IKEBATA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-5000
Mailing Address - Fax:
Practice Address - Street 1:800 E 28TH ST FL 6
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-3723
Practice Address - Country:US
Practice Address - Phone:612-863-5327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-18
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN663842084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry